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Megan Walker: Hello and welcome to Healthcare Online, our special podcast for Allied Health, Specialists and Specialist GPs. And our special guest is Damien Adler, Co-Founder of Power Diary. Hi Damien, how are you?

Damien Adler: Very well, thank you. How are you?

Megan Walker: Very good, thank you. Now, if you're feeling like Deja vu folks, it is the second time we've spoken with Damien in probably as many weeks because we had such an action-packed conversation. Damien and I really had to put the brakes on hard. We covered what Power Diary can do, we looked at improving the value that you offer to your team members to retain them without having to go on that race to the bottom of constantly paying more and more.

We looked at efficiencies to streamline operations. We talked about no show policies and the importance of running a practice that doesn't create practitioner stress. So that was a lot that we covered. So that was episode 14. So if anyone's interested in going back and having a look at that, it is where you are finding this one.

So today we are going to cover part two. We had a such a long list and we were overly ambitious.

Megan Walker: We're going to talk about the tension that I see so many practitioners, therapists, and clinicians face when charging, that that fear of charging, that creeping feeling of self-worth that comes in, that muddies the waters there, fair charging for the value delivered.

We're going to be talking about NDIS charging and the changes that we've seen around that. Diversification and going national, not just local. So, Damien. What do you reckon? How does all that sound?

Damien Adler: I think we have set ourselves an ambitious target again, but I think we can do it.

Megan Walker: I love it. I love it.

So let's start with that self-worth that comes up now. You and I have both been in this space a long time. You're a psychologist, you're now got Power Diary. You know, I've been in this space for 27 years. It is such a common conversation that I'm sure you have had as well as I've had of I can't possibly charge X amount. I am a healthcare professional, I'm in this to help, the greater good, money is dirty, evil and wrong. My services should be free. So can you start with a reframe around that self-worth getting in the way of running a business?

Damien Adler: Yeah, look, I think that the first thing to sort of pull up there is around this idea of that the healthcare should be free.

I happen to think it would be fantastic and I would actually support higher taxes and more like directly paid for healthcare. Because I think healthcare is super important, but given that isn't the case and it's really at a government level to kind of fix that, right?

That if there are people that struggle with accessibility and so forth due to costs, that's actually something that sits at a government level. And we can do things via our associations and so forth on that, but it can't sit with the individual practitioner. And I think it's important that as practitioners we kind of separate ourselves from that, that ideal and say, what is the reality of where we operate.

And then look at it realistically based on that, right? And not try, because it, it's impossible to do right thing. If you want to say we're going to make it super accessible because we have a limited amount of time, you know, essentially to sell. If we think of it in those terms and therefore the return we get on that, that's, you know, what we're primarily where most income is coming from.

Although as we'll talk about, there's also other ways of expanding that, but we need to sort of separate those things out and understand that yes, we operate in a system where healthcare is run as a business. We didn't create that scenario, but that is the reality we're in. And then we need to look at that with a clear eye and say how we see people charging. Sort of unnecessarily discounted rates across the board to everyone, right? Which means that their, their charitable instinct is being sort of diluted by indiscriminate application of that, right? It's getting applied to across everyone. It's much better, in my mind, to charge what is fair and reasonable, which is usually a lot more than what clinicians subjectively feel that they should be charging.

You can do some pro bono work or target right at the population that is truly going to benefit the most from it. And that has a bigger impact and it leaves it in the control of the practitioner because they can determine how much time they provide pro bono or heavily discounted work.

But those options only become available when the charging overall is at a level that you can run a healthy, financially successful practice and not be stressed out about money. Because if you are, if your practice is struggling and you're uncomfortable with raising rates and things like that, then your ability, your power to actually help those that might actually benefit is impaired anyway. Not sustainable. That's my take.

Megan Walker: I love it. I saw an example once, and I want to hear your thoughts on this. It was a GP practice, so I know you are predominantly in the allied health world. But it was a situation where they said we have a thousand dollars hardship budget a month.

So if anyone needs to bulk bill, we can draw from it. It was quite a big practice and a lot of clinicians. And then once that hardship budget is up, we actually cap it and say, we've reached the limit on what the practice can sustain. We hold that over to next month. Have you seen examples like that or capped amounts that people have in their practice?

Damien Adler: I haven't seen it as publicly done like that. And, you know, it's a really interesting idea. But I've certainly seen a lot of people do that behind the scenes and in fact it is one of the things you can do in our system is run reports and see how many of these discounted services are we offering.

Then you can keep like a really good eye on what the ratios are of those things. But I think that the broader point of that practice is doing, the take home there is making a clearly defined thing that they're doing, capping it so they've got a constraint on it, right? So that they're not compromising the success of the practice and the viability of the practice. But also, allowing themselves to provide those services in a way that reaches the people that really do need it and are going to benefit the most.

Megan Walker: Yeah. Nice. Boundaries. So I have another thought for you. One of the most popular posts I've ever put on social media was along the lines of, what story are you telling yourself about your client's financial situation?

Because I've had so many people say, oh my clients will never pay $200 an hour for a session. They can't afford it. They're all struggling. It's difficult financial times. My clients will not pay that. And can you give us a reframe around, well, I know personally I've had financial hardship in my life and a medical situation's come up and I found that money, I reprioritise things and that was my decision. That was my call. Reframe the statement.

Damien Adler: I agree this is a trap that people fall into. We don't really truly know the circumstances of our clients. And we also don't know how resourceful they are and in the experience that we had directly in the clinic, but we also see it when working with customers. People are quite creative when it comes down to for instance, when we put prices up when we had our psychology practice, we would get people that we were concerned about, that we might lose and whatnot. But it's amazing how, if they truly couldn't afford it, how other people will come. So it may be family, it might be workplace.

There's often ways that people go, hey I don't want to be discontinued, or where people have been able to do simple things like we rearrange the appointment timing, so it falls on a pay cycle and they get the rebate or whatever it might be applicable and they do it.

So I think the idea that it's usually an anxiety that does not come into fruition in the way that people think it will when they put the prices up and it's going to be this mass drop off, I think that people have a way of prioritising the things that are important to them.

And this is a different context, but take people who are smokers. And how even with all the tax and people have found a way to continue smoking, right? Which is an extreme example, but when people are motivated, they can often find ways to do things. So I think it's somewhat of a distraction.

We need to kind of go back to the core thing about what can I control? Well you know, I need to be able to run a practice, sustainable, successful and that gives you the financial reward for the risk you're taking and your experience and the qualifications and so forth. Let that be the guiding principle there.

And then let other things fall when they do. But the other point that I would make, because I think sometimes increasing prices, you expect there will be a dip.

Increase your charges by 25%, right? And let's say worst scenario, you got 25% less referrals. You are still well and truly ahead, because you are getting the same money, but you are only working 75% of the time of what you are now. And so with that remaining 25%, you can do whatever. You can have fun and have better work life balance if that's what you want.

But you could also apply that to build other things that might generate income. So it might be you want to write the book, it might be to develop an e-course that is going to provide ongoing recurring revenue to your practice. So even if there is a dip, that does not mean that you made a mistake in doing that.

It's about assessing that and seeing where it lies. But dropping referrals and having more time through other things, that's still a win.

Megan Walker: Yeah, absolutely. A huge win. Now I want to ask you a question about NDIS charging, and this is a whole can of worms. Yeah. So I'm more thinking from the angle that we have seen prices jump up. I remember 17 years ago when I first started this business, we had dieticians that couldn't survive as private practices. They were at the max that they could charge like $80 a session. They were earning $60,000 to $80,000 a year if they went out and worked for themselves.

There wasn't any rebate available. This was pre EPCs, pre mental health care plans and all of that. It was if you want it, you pay for it. And the most you'll ever be able to get back on an appointment is through your private health. 

You're much younger than I am, Damien, do you remember those days?

Damien Adler: Probably not as much as you might.

Megan Walker: So would you agree that one thing NDIS and other schemes have done is create a more fair playing field in pricing in terms of covering more of the hard costs and the realities in private practice? Tell me your thoughts.

Damien Adler: Absolutely. And I think the best indication of this is when you look at what the professional associations have in terms of their recommended fees, right?

Because they usually, I think, do a pretty good job of dialing into you know, roughly what the cost are, what's reasonable. They're looking across other industries and other comparable professions. And I mean, I don't always agree with where they land, but it's usually a much better job than what the individual practitioner does, right.

Typically the recommended fees are much higher than what people feel they can get away with charging. Now NDIS is I think better aligned with the true cost of running these services. And I think to draw people into private practice and make sure these services are available and to encourage people into the industry it needs to be viable and it needs to be a return on the effort, the education and the risk that goes with running a practice and all the stresses that kind of go with that, right? So I sort of more see that that price jump that we see, that's more actually of a correction rather than it being something of a distortion.

Now we know that okay, there are cases. And there's certainly examples where people do the wrong thing, right? And NDIS has been full of examples of where it's been misused and there's been fraud and so forth.

So let's put that aside and say yes that needs to be dealt with. But overall, the fact that charges more it's not out of the realms of what it actually costs to run a practice and to engage and provide a great, qualified, registered service.

So I think there's that. The other part of it to think about is the actual compliance costs and the administrative costs around performing work under NDIS as they don't pay for all of that hidden costs of changing plans, making sure things align and the funding's there, tracking it. It's a complicated piece of machinery there that needs to be managed. And if it goes wrong, it's the practitioner or the practice that wears it, like the number of times people provided services etc.

So broadly that's my hot take on that.

Megan Walker: It just always strikes me as really funny that we have these more emotionally-charged conversations around pricing for health practices. If this was another type of professional service, an accounting firm, legal firm, architect, it wouldn't have that emotional charge to it, it would be this is the hourly rate. We are keeping the lights on, paying for stamps, paying for carpet washed every year, paying for fire extinguishers like the. It is such a fact-based business, those other professional services. But when we say health practice, well ...

Damien Adler: That's right.

If you look at the legal profession and you look at the charges and some of the charges on there for things like photo-copying? I think in health it's a combination of communication expectation and then the sort of people who get into healthcare obviously are typically motivated to help others and altruistically want to make a positive impact.

Speak to the government, to your local representative about increasing the funding available. If it's a Medicare rebated service, ask about increasing the rebates. If it's not a Medicare rebated service, talk to your local representative and make it an issue with them, because that's really where the change will come about.

I won't go on too much of a tangent here, but if you think about what they'll spend on medication, right? Subsidizing medication and some of these biological interventions, which is great, but actually if we did some preventative work in the allied health setting we can see in research we're going to get like an economically good outcome as well as.

So it's all about making sure that where there are those things we point the energy and the heat and the concern in the right direction. It shouldn't be at practitioners and it shouldn't be a practitioner turning on themselves. But turn onto the government of the day and make it an issue. And enough people do that. That's where change comes about.

Megan Walker: I could listen to you talk about this for ages because sometimes I don't have the words and I hear the tension from people bringing up these issues over and over again. And I think, why does it have such a different feeling to it than other businesses?

But I really like how you brought together all of those, those factors that altruism is such a big one. So we're not having a go at anyone. We're just trying to give suggestions.

Damien Adler: No, totally.

Megan Walker: And in terms of growth, and this is our sort of our last kind of conversation and path that we're going to go down, is I've often seen practices over the years exposed to high risk affected by bush fire and had to close completely. Other practices, affected by floods like in Lismore and those are horrible situations that, I didn't realise at the time, were starting to lead me down this path of healthcare courses. And especially with Covid, like what is going to sustain the practice if one of these big impacts hits? And some of these things are highly unlikely.

But what's your thoughts, Damien, on diversifying so that you don't have all of your eggs in one basket, so that if four other physios open in the same street you don't run out of business. Tell us your thoughts about that diversification to drive sustainability of the practice.

Damien Adler: I'm a very visual person, right? Like in how I think. And so the way that I think about this... diversification is almost like the foundations that are holding up a building, right?

So imagine a building on stilts. You're in Queensland, plenty of that. So diversification is like how many posts are holding up that practice?

So in the worst case scenario you have one center post. That might seem pretty strong, right? And that one is where you have businesses that have sort of one modality on premises, maybe even solo practitioner or it might be a thriving business on one level, right? But it is still one thing and anything kind of impacts that, right? And takes that out for whatever reason. Could be all the things that you mentioned or something we didn't see coming, like covid.

 So each of the pillars that we can put in place, keeping the practice supported, means that the importance of any one of those is then reduced and it makes the practice far more versatile.

So when we think about things like online courses, when we think about expanding to doing telehealth, when we think about expanding to have other people potentially providing services, employing or engaging other people in the practice. So diversifying those kind of income streams. If something happens to any one of those things, then the rest is there to kind of support and even our own practice.

And if Medicare was the sort of dominant thing and a lot of practices were solely focused on Medicare, and we took a decision early on that we would expand out. We would still have, we used to call Medicare the bread and butter. Okay. That's sort of like a primary support but still government funded.

It was the early days of Medicare, so subject to government change, which actually did happen. They reduced it from 18 maximum down to 10 sessions for psychologist. But we also nurtured relationships with local organisations, nonprofits. We did a lot of corporate work. We did picked up EAPs.

We did a whole bunch of other things so that if something fundamentally changed with say Medicare or with a particular modality, we would have other supports that we already had the relationships built. We already had income streams and we could turn them up if we needed to. So doing training for NGOs, government and larger companies if we needed to, we could dial that right up and become like a training organisation if we really had to. Each industry will be different in each context, but when you sit down and think about it, here's my foundations, what's holding it up right now? If it's just me? If it's one practitioner, okay, so what can you do to kind of shore that up? It may even be things like making sure you have income protection insurance, right? To shore that because when you look at it from a risk assessment point of view you might think okay maybe some of these things I don't want to do, but I do need to shore up a few of these things from an income point of view.

It can be things like insurance, but if you're thinking practice wise, it could be all the other things as well. We've been around for a long time now, and so we've seen a lot of stuff happen over the years. We've seen people flooded out, you know, whole regions just flooded, gone.

We've seen practices that have burnt down. We've seen practice that have been like that. And we're seeing unfortunately, practitioners pass away or get ill and so you can see the resilience. Often it comes down to how many other things they have in place that support it.

And the ones that are well positioned sail through a lot better than the ones where it's a solo support. Something takes that out and then they're in real trouble very quickly.

Megan Walker: So well said. I love your stilt analogy, especially the Queenslander reference.

It's so true. Take it out and what legs is it standing on literally?

Years ago, and I'll start wrapping up soon, but I did have a situation I'm sure I've told you about, there was a big practice in a regional area with quite a specific area of physiotherapy.

 Four senior physios in that practice left and popped up in the area. So we went from one big one to then five practices with not enough client base in that drivable area. So there's all sorts of things that weren't great about that situation, but something that really stuck in my mind from seeing that, and each one of them rang me and said, we need marketing help. And I was like major conflict of interest. You got the one that you actually just left, you know, how is your restraint of trade? Anyway, separate conversation for another day. But something that just stuck with me forever was if you don't have enough clients in your local, drivable area and you want to niche down in a particular space, then sitting there and going, well I've only got three clients this week, there isn't enough to keep the doors open. So telehealth and what you mentioned and even choosing your niche, but thinking of it nationally, I've always been a huge advocate of that.

Tell me your thoughts on thinking beyond that drivable area.

Damien Adler: Absolutely and I think to put even more to it, It really surprised us actually in Covid, right?

Because like when we were sort of assessing and looking at things, we were thinking, well okay, I can see obviously mental health, psychology, counseling that's going to pivot online pretty well, right? But we were more concerned about like the physios and massage therapist who have a very tactile experience and we were particularly concerned about their wellbeing. What was amazing, you know, is to see that under the pressure of that, how creative people were. And it was amazing to see that they tried things outside their comfort zone.

 What is the core active ingredient in what they're providing, right? And so with a physio, you know, or an osteo or you know, where you'd think surely it's very tactile. But then they were able to pivot to demonstrating exercises, doing more video content. Deliver services or tangential things.

If I had sat there and tried to brainstorm it, I wouldn't have come up with that outside of the real need to do it. And it was really inspirational to talk to these different practices that worked, how to pivot.

Necessity as mother of invention. Think about that outside of a crisis and go, yeah, what is out? If you've got a situation like that, you're geographically isolated or often we'll see someone, a health practitioner is in an area where there aren't many patients, but they're there because their spouses has got a job that that requires them to be there.

You know, and they're sort of a little bit stuck, but when you think about that expanding outside of that it can work so well. I think it's that going outside your, your comfort area or what you are comfortable with, you know, what you're used to. We can do our core stuff but what could I do or what would happen if I absolutely needed to. What other services could I provide? And it works so well and better than that because people often find what they really enjoy and have a whole different way of delivering it or packaging like what they do.

All for it. And I think this is the beauty of the technological age that we're in too that you can have a satellite and get links. You be running batteries right?

And you can operate your health practice from the side of a mountain if you want. Fantastic. And that's unique and exciting and leads to more robust practices.

Megan Walker: Yeah. So good. You, you made me think of a physio practice that had said to their clients - are you locked up at home? Guess where you can go? You can come and see us during covid come in for a release and assessment and a chat, and most importantly, a chat with a human being.

Damien Adler: Yeah. Give it to it. And away you go.

Megan Walker: Mobile Mani Pedi from the podiatrist.

Anyways, I'm gonna get a backlash from saying that. Damien, thank you so much for such a great conversation. I love the fact that we fundamentally talked a lot about emotional responses to money in a way seem to be our theme for this this chat which is going to be so helpful for so many people.

Where can folks go and find out more about Power Diary? You've got a free trial as well. Tell us about that.

Damien Adler: Yeah, absolutely. You can jump onto our website com and start a free trial. We've also got our team members there that you can jump on a chat or book a call in with them. And, you know, we can help out any way.

Then we can help automate your practice. Away you go. Been around for a lot of years now and we really like helping people with these sorts of conversations. It's really what I love doing to thank you very much for having me on.

 Megan Walker: Absolutely been fun as always. Thanks Damien. Really appreciate your wisdom and we'll talk to you soon. 

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